Stephanie C. Wu

Use of Pressure Offloading Devices in Diabetic Foot Ulcers: Do we practice what we preach?

OBJECTIVE—Pressure mitigation is crucial for the healing of plantar diabetic foot ulcers. We therefore discuss characteristics and considerations associated with the use of offloading devices. RESEARCH DESIGN AND METHODS—A diabetic foot ulcer management survey was sent to foot clinics in all 50 states and the District of Columbia in 2005. A total of 901 geographically diverse centers responded. The survey recorded information regarding usage frequency and characteristics of assessment and treatment of diabetic foot ulcers in each center. RESULTS—Of the 895 respondents who treat diabetic foot ulcers, shoe modifications (41.2%, P < 0.03) were the most common form of pressure mitigation, whereas total contact casts were used by only 1.7% of the centers. CONCLUSIONS—This study reports the usage and characteristics of offloading devices in the care of diabetic foot ulcers in a broadly distributed geographic sample. Less than 2% of specialists use what has been termed the “gold standard” (total contact cast) for treating the majority of diabetic foot ulcers.

Assessing postural control and postural control strategy in diabetes patients using innovative and wearable technology.

Introduction: Currently, diagnosis of patients with postural instability relies on a rudimentary clinical examination. This article suggests an innovative, portable, and cost-effective prototype to evaluate balance control objectively. Methods: The proposed system uses low-cost, microelectromechanical sensor, body-worn sensors (BalanSens™) to measure the motion of ankle and hip joints in three dimensions. We also integrated resulting data into a two-link biomechanical model of the human body for estimating the two-dimensional sway of the center of mass (COM) in anterior-posterior (AP) and medial-lateral (ML) directions. A new reciprocal compensatory index (RCI) was defined to quantify postural compensatory strategy (PCS) performance. To validate the accuracy of our algorithms in assessing balance, we investigated the two-dimensional sway of COM and RCI in 21 healthy subjects and 17 patients with diabetic peripheral neuropathic (DPN) complications using the system just explained. Two different conditions were examined: eyes open (EO) and eyes closed (EC) for duration of at least 30 seconds. Results were compared with center of pressure sway (COP) as measured by a pressure platform (Emed-x system, Novel Inc., Germany). To further investigate the contribution of the somatosensory (SOM) feedback to balance control, healthy subjects performed EO and EC trials while standing on both a rigid and a foam surface. Results: A relatively high correlation was observed between COM measured using BalanSens and COP measured using the pressure platform (r = 0.92). Results demonstrated that DPN patients exhibit significantly greater COM sway than healthy subjects for both EO and EC conditions (p < 0.005). The difference becomes highly pronounced while eyes are closed (197 ± 44 cm2 vs 68 ± 56 cm2). Furthermore, results showed that PCS assessed using RCI is significantly better in healthy subjects compared to DPN subjects for both EO and EC conditions, as well as in both ML and AP directions (p < 0.05). Alteration in SOM feedback in healthy subjects resulted in diminished RCI values that were similar to those seen in DPN subjects (p > 0.05). Discussion/Conclusion: This study suggested an innovative system that enables the investigation of COM as well as postural control compensatory strategy in humans. Results suggest that neuropathy significantly impacts PCS.

Outcomes of allogenic acellular matrix therapy in treatment of diabetic foot wounds: an initial experience

The purpose of this study was to evaluate outcomes of persons with UT grade 2A neuropathic diabetic foot wounds treated with an acellular matrix. Data were abstracted for 17 consecutive patients with diabetes – 76·5% males, aged 61·5 ± 8·5 years with a mean glycated haemoglobin of 9·2 ± 2·2% presenting for care at a large, multidisciplinary wound care centre. All patients received surgical debridement for their diabetic foot wounds and were placed on therapy consisting of a single application of an acellular matrix graft (GraftJacket™; Wright Medical Technologies, Arlington, TN, USA) with dressing changes taking place weekly. Outcomes evaluated included time to complete wound closure and proportion of patients achieving wound closure in 20 weeks. Acellular matrix therapy was used as initial therapy and was sutured or stapled in place under a silicone‐based non adherent dressing. Therapy was then followed by a moisture‐retentive dressing until complete epithelialisation. In total, 82·4% of wounds measuring a mean 4·6 ± 3·2 cm2 healed in the 20‐week evaluation period. For those that healed in this period, healing took place in a mean 8·9 ± 2·7 weeks. We conclude that a regimen consisting of moist wound healing using an acellular matrix dressing may be a useful adjunct to appropriate diabetic foot ulcer care for deep, non infected, non ischaemic wounds. We await the completion of further trials in this area to confirm or refute this initial assessment.

Risk assessment of the diabetic foot and wound

Diabetic foot ulcers are among the most common severe complications of diabetes, affecting up to 68 per 1000 persons with diabetes per year in the United States. Over half of these patients develop an infection and 20% require some form of amputation during the course of their malady. The key risk factors of diabetic foot ulceration include neuropathy, deformity and repetitive stress (trauma). The key factors associated with non healing of diabetic foot wounds (and therefore amputation) include wound depth, presence of infection and presence of ischaemia. This manuscript will discuss these key risk factors and briefly outline steps for simple, evidence‐based assessment of risk in this population.

Wound care: The role of advanced wound-healing technologies

Wound repair and regeneration is a highly complex combination of matrix destruction and reorganization. While major hurdles remain, advances over the past generation have improved the clinicians armamentarium in the medical and surgical management of this problem. The purpose of this manuscript is to review the current literature regarding the pragmatic use of three of the most commonly employed advanced therapies; namely, bioengineered tissue, negative pressure wound therapy, and hyperbaric oxygen therapy with a focus on the near-term future of wound healing, including stem cell therapy.

A growing troubling triad: diabetes, aging, and falls.

There is a significant and troubling link between diabetes (DM) and falls in the elderly. Individuals with DM are prone to fall for reasons such as decreased sensorimotor function, musculoskeletal/neuromuscular deficits, foot and body pain, pharmacological complications, and specialty (offloading) footwear devices. Additionally, there is some concern that DM patients are prone to have more severe problems with falls than non-DM individuals. Fractures, poorer rehabilitation, and increased number of falls are all concerns. Fortunately, efforts to mitigate falls by DM patients show promise. A number of studies have shown that balance, strength, and gait training may be utilized to successfully reduce fall risk in this population. Furthermore, new technologies such as virtual reality proprioceptive training may be able to provide this reduced risk within a safe training environment.

Validation of a diabetic foot surgery classification

The purpose of this project was to evaluate associations of increasing diabetic foot surgery stage with postoperative outcome. This project, designed as a retrospective cohort model, was conducted at three large, urban referral‐based diabetic foot clinics. The investigators abstracted medical records from 180 patients with diabetes, 76·1% male, aged 57·8 ± 11·2 years, falling equally into four classes of a previously reported diabetic foot surgery classification system. These classes included class 1 (elective), class 2 (prophylactic), class 3 (curative) and class 4 (emergency). There was a significant trend towards increasing risk of ulceration/reulceration (χ2trend= 17·8, P= 0·0001), peri‐postoperative infection (χ2trend= 96·9, P= 0·0001), all‐level amputation (χ2trend= 41·7 P= 0·001) and major amputation (χ2trend= 8·6, P= 0·003), with increasing class of foot surgery. The results of this study suggest that a non vascular foot surgery classification system including variables such as the presence or absence of neuropathy, an open wound and acute infection may be predictive of peri‐ and postoperative complications. This may assist the surgeon in better identifying risk when determining a rationale for and type of surgery in persons with diabetes.

Clinical outcome of diabetic foot ulcers treated with negative pressure wound therapy and the transition from acute care to home care

Diabetic foot ulcers affect millions of people in the United States of America and impose tremendous medical, psychosocial and financial loss or burden. Negative pressure wound therapy (NPWT) is generally well tolerated and appears to stimulate a robust granulation tissue response compared with other wound healing modalities. This device may be a cost‐effective adjunctive wound healing therapy. This literature review will focus on the clinical outcome of diabetic foot ulcers treated with NPWT, its implication in the transition from acute care to home care, factors that might influence clinical outcomes in home care as well as quality‐of‐life aspects in these patients. Patient care for diabetic foot ulceration is complex and necessitates multiprofessional collaboration to provide comprehensive wound care. It is clear that when we strive for limb preservation in this most high‐risk population, it is important to have an available versatile, efficacious wound healing modality. There is a need for an easy transition from acute care to home care. Resources need to be combined in a collaborative and synergistic fashion to allow patient to perform many daily living activities while receiving the potential benefits of an advanced wound healing modality.

Does the Diabetic Foot Have a Significant Impact on Selected Psychological or Social Characteristics of Patients with Diabetes Mellitus

The aim of our case-control study was to compare selected psychological and social characteristics between diabetic patients with and without the DF (controls). Methods. 104 patients with and 48 without DF were included into our study. Both study groups were compared in terms of selected psychosocial characteristics. Results. Compared to controls, patients with DF had a significantly worse quality of life in the area of health and standard of living as shown by lower physical health domain (12.7 ± 2.8 versus 14.7 ± 2.5; P < 0.001) and environment domain (14.1 ± 2.2 versus 15 ± 1.8; P < 0.01) that negatively correlated with diabetes duration (r = −0.061; P = 0.003). Patients with DF subjectively felt more depressed in contrast to controls (24.5 versus 7.3%; P < 0.05); however, the depressive tuning was objectively proven in higher percentage in both study groups (83.2 versus 89.6; NS). We observed a significantly lower level of achieved education (P < 0.01), more patients with disability pensions (P < 0.01), and low self-support (P < 0.001) in patients with the DF compared to controls. In the subgroup of patients with a previous major amputation and DF (n = 6), there were significantly worse outcomes as in the environment domain (P < 0.01), employment status, and stress readaptation (P < 0.01) in contrast to the main study groups. Conclusions. Patients with DF had a predominantly worse standard of living. In contrast to our expectations, patients with DF appeared to have good stress tolerability and mental health (with the exception of patients with previous major amputation) and did not reveal severe forms of depression or any associated consequences.

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